23 Augustus 1975 A MEDIESE TYDSKRIF 1459

Acute Appendicitis •In PregnancyG. W. E. RbSEMA

SUMMARY

Acute appendicitis in pregnancy and its treatment arereviewed. Six cases are described. Early surgery isrecommended, and a conservative watchfulness for morethan 4 to 6 hours is condemned.

S. A fr. Med. J. o 49, 1459 (1975).

Acute appendicitis in pregnancy deserves special attentionbecause of its very high maternal and fetal morbidity andmortality rates. According to the literature since 1950,the mortality seems to have decreased since the introductionof antibiotics. There can, however, be no grounds forcomplacency when young women are still dying from thiseasily curable disease. The most important reason for thehigh mortality and morbidity is an inability to make anearly diagnosis and to institute prompt operative treatment.

The incidence of appendicitis in pregnancy in 1935was quoted as being 1: 2 000 pregnancies.' In 1944, theincidence quoted by Child and Douglas' was 1: 1 000 anda report in 1972 showed the incidence to be 1: 704.'It therefore appears that this condition is becoming morecommon. Aird' pointed out that appendicitis is a diseaseof modern civilisation, caused by a sedentary life, anda high-residue flesh diet. Until about 5 to 10 years ago,appendicitis in the Black population of South Africa wasrare, but it is becoming more common, which supportsthe above hypothesis.

Since appendicitis in pregnancy is not a common con­dition, the personal experience of anyone clinician islikely to be limited. Therefore, the author's experienceof 6 cases may be of value, if only to demonstrate thatan inability to make the proper diagnosis incurs a delaywhich gives rise to complications. This is well demonstratedin the first two cases.

CASE REPORTS

Case 1

A Coloured woman, aged 30 years, gravida 3, para 2,presented at 34 weeks' gestation with upper abdominal painof a cramp-like nature, which was associated with nauseaand vomiting, and she also had dysuria. She had no historyof a similar complaint.

Department of Obstetrics and Gynaecology, 1)'gerbergHospitaJ and University of SteUenboscb, ParowvaJlei, CP

G. W. E. ROSEMAN T, M.B. CH.B., M.R.e.O.G., Senior Part-timeConsultant and Lecturer

Oat" received: 25 March 1975.

l

Examination revealed that her temperature wa 38°C,her tongue was furred and her pulse rate was 100 I min.She wa found to be 34 weeks pregnant on ob tetricexamination. There was rebound tenderness, maximal inthe right upper quadrant, and no rigidity, but guarding.Alder 's sign was present and ballottement was painful.

An acute urgical abdomen was diagnosed and thepatient was referred to a teaching hospital where degene­ration of a fibroid was diagnosed. Her condition did notimprove and she was then referred to the surgical out­patient department with the confident diagnosis of appen­dicitis in pregnancy. The patient returned with a crypticnote, which stated that the condition was not surgical.Her condition deteriorated and an emergency laparotomyrevealed a ruptured appendix. Appendicectomy wa per­formed, the abdomen was drained, and antibiotic wereadministered. She made a remarkably uneventful recoveryand delivered at term a male infant of 2950 g.

Case 2

A White woman, aged 33 years, gravida 6, para 5, whowas 22 weeks pregnant, presented with a history of para­umbilical cramp-like pain of 2 days' duration. The painsettled in the right loin and was not associated withnausea or vomiting. She experienced severe dysuria andfrequency, and had in the past had similar episodes of painin the right iliac fossa.

On examination, she was apyrexial, had a furred tongue,and her pulse rate was 88/min.

Abdominal examination revealed that she was 22 weekpregnant. There was tenderness, mainly in the right loin,and extreme tenderness on bimanual palpation. There wasmuscle-guarding but no rigidity, or rebound tenderness.Alder's sign was absent. Ballottement was painful, andthe heel-stamping sign was present. The urine containedalbumen and red blood cells.

A diagnosis of renal tone was made and an intravenouspyelogram with a single exposure was ordered (Fig. I).This revealed obstruction of the right ureter at the pelvicinlet. The patient was therefore referred to a urologistand a retrograde pyelogram which wa performed 2days later confirmed an extralurninal obstruction (Fig. 2).Laparotomy was performed and a perforated retrocaecalappendix with an abscess which compressed the ureterwas found.

Appendicectomy and drainage of the ab cess werecarried out and antibiotics were administered.

The patient, however, remained critically ill for about5 weeks and developed subphrenic abscesses, intestinalobstruction, wound infections and multiple abdominalabscesses, which necessitated surgical drainage on 5occasions.

1460 SA MEDICAL JOUR TAL 23 August 1975

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Fig. 1. Intravenous pyelogram showing obstruction ofright ureter at pelvic brim.

Fig. 2. Retrograde pyelogram showing obstruction ofright ureter.

Seven weeks later, she was examined again when shewas thought to be about 29 weeks pregnant, but the sizeof the uterus corresponded to that of a 22 weeks' pregnancy.Termination of pregnancy was strongly suggested becauseof the excessive irradiation to which she had been submittedduring her illness, and because of the various antibiotics

which had been admini tered and which might have beenharmful to the fetus.

In view of the fact that there was gross retardation ofintra-uterine growth it was anticipated that she would abortspontaneously, and this did happen one week later whenshe delivered a macerated male infant who weighed I 200 g.She slowly regained her health.

Case 3

A White woman, aged 23 years, gravida I, para 0, whowas 20 weeks pregnant, presented with a history of acute,central, abdominal pain which lasted for I day andsettled in the right loin. It was associated with nausea,but not with vomiting. She also experienced rigors, andthe pain radiated into the right leg. She had never had asimilar experience.

On examination, her temperature was found to be 38 Q C,her pulse rate was 94/min and her tongue was normal.

Abdominal examination revealed that she was 22 weekspregnant. There was maximal pain in the right loin andmuscle rigidity, but no rebound tenderness. Alders's signwas present. Ballottement was painful and the heel-stampingsign was present. Urine was normal.

No improvement occurred over 6 hours, her pulse rateincreased and a laparotomy was performed. A retrocaecal,acutely inflamed appendix was removed. The right ovaryand tube were normal. Histological examination confirmedacute appendicitis.

She recovered rapidly and delivered at term a healthyfemale infant of 3 540 g.

Case 4

A White woman, aged 28 years, gravida 3, para 2,presented at 32 weeks' gestation. She had developed acute,upper abdominal, cramp-like pain, accompanied by nauseaand vomiting. Initially, an acute spastic colon was diag­nosed, but over 24 hours her condition deteriorated.The pulse rate increased and she was also very tenderin the para-umbilical area. There was no history of previouspain in the right iliac fossa, and no urinary symptoms.

Examination revealed that her temperature was 36,4QC,her pulse rate was 90/ min and her tongue was not furred.

She was 32 weeks pregnant and had rebound tendernessin the right loin. There was no rigidity, but guarding waspresent. Alders's sign was absent, but ballottement waspainful and the heel-stamping sign was present. A diag­nosis of acute appendicitis was made.

At laparotomy an acutely inflamed appendix with agangrenous tip was found.

Postoperatively, she went into premature labour, butwith conservative treatment she eventually had an un­complicated postoperative period. She delivered at terma normal female infant of 3 400 g.

Case 5

A White woman, aged 24 years, gravida 1, para 0, whowas 20 weeks pregnant, presented with abdominal pain

23 Auguslus 1975 SA MEDIESE TVDSKRIF 1461

of a cramp-like nature, which radiated to the back; therewas no dysuria, nausea, or vomiting. She had had aprevious episode of pain in the right iliac fossa during 1972.Initially, her condition was diagnosed as pyelonephritisand treated with antibiotics, but her condition deteriorated.

On examination, her temperature was 38,2°C, her tonguewas furred and her pulse rate was lOO/min.

Abdominal examination revealed that she was 20 weekspregnant. There was tenderness in the right loin but norebound tenderness or rigidity; there was some muscleguarding. Alders's sign was present, and ballottementwas painful; the heel-stamping sign was present, andpsoas muscle spasm was detected.

A diagnosis of acute appendicitis was made, laparotomywas performed, and an acutely inflamed appendix wasfound and removed. The postoperative course was un­complicated and she delivered at term a healthy femaleinfant of 3 345 g.

Case 6

A White woman, aged 27 years, gravida I, para I, whohad been delivered by forceps for delay in the secondstage of labour 2 days before, suddenly developedcramp-like abdominal pain with nausea, but no vomiting.The pain was predominant in the right iliac fossa andradiated into the right leg. Pyrexia of 38°C and progressivetachycardia of 140/min developed in 4 hours.

She had had repeated episodes of right iliac fossa painduring the past year. During her pregnancy she had hadan episode of pain in the right loin which was diagnosedand successfully treated as pyelonephritis.

On examination, her pulse was 140/ min, her tempera­ture was 38,4°C and her tongue was furred.

Abdominal examination revealed an involuting uterus2 finger-breadths below the umbilicus, which was nottender except on movement. Alders's sign was present.Psoas spasm was detectable, and the heel-stamping signwas present. A diagnosis of acute appendicitis was made.Laparotomy revealed a normal involuting uterus andappendages. The appendix was retrocaecal and acutely in­flamed at the tip. Appendicectomy was performed and thepostoperative course was uneventful.

DIAGNOSIS

The single most important cause for the high mortalityand morbidity of acute appendicitis is the inability tomake a diagnosis early enough to institute adequatetreatment.

The diagnosis of appendicitis in pregnancy is difficult,but once awareness of this association is aroused, thecorrect diagnosis can be made, as demonstrated by thelast 4 case histories above.

The differential diagnoses of the acute abdomen inpregnancy included infection, which accounts for 40o~

of acute abdominal emergencies. Of this, appendicitisconstitutes a formidable incidence of 63°~ - 750~:.6 andacute cholecystitis, which includes pancreatitis, diverticulitis,

Meckel's diverticulum and non-specific adenitis, accountsfor IOo~. All other acute conditions of the abdomenwhich may occur during pregnancy are far more rarethan appendicitis, and therefore the diagnosis of appen­dicitis should readily be made.

Intestinal disease, which accounts for 20°" of acuteabdominal emergencies in pregnancy. includes disordersof the upper abdomen, such as pyloric stenosis, hiatushernia, peptic ulceration and intestinal malrotation, anddisorders of the lower abdomen, such as :dhEsions, vol­vulus, intussusception and hernias.

Bleeding accounts for 10o~ of acute abdominal emer­gencies during pregnancy, and may be caused by haema­toma of the rectus sheath, by traumatic or spontaneousrupture of liver or spleen or by various other spontaneousruptures of vessels.

Thirty per cent of acute abdomina! emergencies arisein the genital tract, and include various complications ofovarian tumours, particularly dermoid. fibromyomata andtheir complications, abruptio placentae and advancedectopic pregnancy.

There is no statistical evidence that pregnant womenwho are actually in the age group which runs an appre­ciable risk of acute appendicitis, are more prone to thiscondition than non-gravid women.

Appendicitis in pregnancy carries a very high mortalityand morbidity for the following reasons:

1. Early Perforation

Rupture of the inflamed appendix occurs 2 - 3 timesmore frequently in pregnancy.' It appears that this earlyand frequent perforation could be ascribed to the factthat the omentum has been displaced upwards and isunable to guard the inflamed appendix and, further, thatthere is an increased blood supply in pregnancy whichgives rise to a more marked inflammatory response andincreased vascularity, which produces a softer appendixand earlier perforation.

2. Displaced Appendix

The appendix is displaced upwards, laterally and pos­teriorly (Fig. 3). Because of, this anatomical displacement,the normal clinical signs ascribed to appendicitis are noteasily elicited, and delay in diagnosis is common. Owing toearly perforation of the appendix, which is now situatedin the upper abdomen, generalised peritonitis is inevitable,and has a high complication rate.

3. Delayed Diagnosis

Diagnosis of acute appendicitis in pregnancy is usuallydelayed because, although nausea and vomiting are itsmost common clinical symptoms, they are also verycommon in pregnancy. Abdominal pain in pregnancy isalso frequent and is usually ascribed to some other con­ditions, there being reluctance, or failure, to consider

1462 SA MEDICAL JOURNAL 23 August 1975

Fig. 3. Graphic demonstration of changino positions ofappendix with advancing pregnancy. ..

appendicitis. Also, because the appendix is displaced, theclinical signs are masked. A particular problem in theearly puerperium arises because the anterior abdominalwall muscles are relaxed owing to the orowina uterus andthe anterior abdominal wall is unable ~o resp~nd with theclinical signs of guarding, rigidity, and rebound tenderness.

Because of the absence of the classical signs of appen­dicitis as they occur in non-pregnant patients, there isdelay in diagnosis. This delay leads to complicationswhich may be fatal in the case of the pregnant woman. Thematernal mortality, even in the antibiotic era, is variouslyquoted as being between 1% and 16%, without perforationof the appendix, and it can ri e to 35°(, in the presenceof perforation at virtually all stages of gestation.' In thepuerperium the mortality is much higher because thedelay in diagnosis is invariably even longer. The fetalmortality when perforation has not occurred is said to bebetween 1% and 4% and with perforation it rises to 35°0­50%.~ This high fetal mortality can be ascribed to pre­mature labour or abortion as well as to intra-uterinegrowth retardation as a result of the toxaemia of theinfection and, possibly, to the antibiotics and druas usedto treat this dreaded condition once perforation "'occurs.

The key to improvement of the treatment of appendicitisin pregnancy obviously lies in early diagnosis. so thatearly operative treatment can be instituted.

Suspicion of appendicitis in pregnancy facilitates diaa­nosis. If, after a few hours of observation, the clinic~lpicture does not improve, but remains suggestive of anacute abdomen, exploratory laparotomy is mandatory.Suspicion, and not the constellation of classical clinicalsigns, is the indication for surgical intervention in thepregnant woman with appendicitis.s

Vague pain in the right abdomen and signs of an acuteabdomen are probably the most constant clinical signs

encountered in acute appendicitis in pregnancy. Althoughnausea and vomiting are also common complaints in anormal pregnancy, they should never be disregarded aspossible evidence of appendicitis.

Previous episodes of pain in the right iliac fossa whichmay have arisen from an inflamed appendix, are frequentlye~lclted. when the histories of patients with acute appen­diCitiS 10 pregnancy are taken. This flaring-up of appen­diCitiS during pregnancy could be caused by peri-appendi­cUla~ adhesions and kinking of the appendix. The appen­diX IS moved from its original site as the pregnancy ad­vances and the adhesions and kinking give rise to obstruc­tion, predisposing to acute appendicitis.

As previously mentioned, the appendix is displacedupwards laterally and posteriorly, particularly in advancedpregnancies, and the appendix then lies on or close tothe kidney. Dysuria is therefore a frequent symptom i~patIents with acute appendicitis in pregnancy, and whitecells are commonly found in the urine. This finding shouldnot preclude a diagnosis of appendicitis.. On clinical examination, a furred tongue and an increas­mg tachycardia are the only reasonably constant clinicalsigns. Pyrexia may be conspicuously absent. On localexamination, mild tenderness in the right upper abdomenIS always present. Rebound tenderness. muscle auardin aand rigidity are seldom present because of the lax"'anterio~abdominal muscles whkh have been stretched by thepregnant uterus.

Alders' described a useful clinical test which consists oflocalising the area of maximal abdominal tenderness andmaintaining constant pressure on that point while thepatient is being turned to the left. If the pain is constant.the pain is of extra-uterine origin: if the pain disappear~It IS more likely to be of uterine or tubal origin. This isa very useful and important clinical test which may beemployed m all cases of an acute abdomen in pregnancy.

Ballottement frequently aggravates the pain if it is ofextra-uterine origin.'

Another useful clinical test for the acute abdomen isthe 'heel-stamping sign'.'· The patient, who is standing, isas~,ed to take off her shoes and to separate her heels byabout 15 cm. The examiner then stands in front of thepa~ient .and asks her to follow his movements exactly.WIth his hands on his sides, he stands on his toes andthen suddently relaxes and falls back onto both heels.~f ~he. patient follows suit and has some form of peritonealIrntatIon, she will grasp her abdomen. This has beenfound to be a very accurate clinical test which indicatesperitoneal irritation when other signs are still absent.

Special investigations are of very little use, since preg­nancy causes a leucocytosis, the magnitude of which isusually at least 120001 fLl, and the sedimentation ratei also elevated to at least 20 mm in the first hour'The~ are of very little use unless done serially, so demon­stratmg a progressive rise in both values.

TREATMENT

Immediate appendicectomy at all stages of pregnancy isthe treatment of choice. The risk of a laparotomy to

23 Augustus 1975 SA MEDIESE TYDSKRIF 1463

mother and fetus is very Iow with modern anaesthesia.The dangers which may result from a negative laparotomyare not great and, therefore, early surgery for suspectedacute appendicitis at all stages of pregnancy is stronglyadvocated."

It is of paramount importance to desist from Caesareansection at the time of the appendicectomy, no matter whatthe period of gestation. It is rather to be recommendedthat these patients be allowed to go into spontaneouslabour even shortly after the appendicectomy, than thatthey should undergo Caesarean section.s

The reason for this conservative approach is thatCaesarean section would tend to spread infection to afresh wound. The infants also frequently suffer severesepsis if they are delivered by Caesarean section at thetime of appendicectomy, particularly if the appendix isruptured and peritonitis is present.

The stress on a fresh scar is not severe in labour, butit probably increases with the pregnancy. Epidural anaes­thesia is ideal for patients with fresh scars, provided thatthey are not septicaemic. Elective forceps delivery withfull dilatation is then recommended·

The incision of choice should be a right paramedianincision at the level of maximal tenderness. The incisionshould be big enough to allow the whole hand to enterto lift out the laterally, and frequently posterioriy displacedcaecum and appendix. Appendicectomy should always beperformed if possible, even if the laparotomy reveals anormal appendix.' Drainage is only advised if peritonitisis present. Operative exposure is further facilitated if thepatient is turned 30° to the left. and if the assistant makesuse of a Dever's retractor to pull the abdominal walllaterally. It cannot be sufficiently stressed that there shouldbe as little manipulation of the uterus as possible, toprevent premature onset of labour or abortion.

Postoperative antibiotic cover is advocated, particularlyin patients with peritonitis, and a state of adequatehydration is essential.

The complications will be infrequent in appendicitis in

pregnancy if early surgery performed. Maximal com­plications occur with delayed surgery, as in the secondcase history described above. Complications which mightarise in patients who ha e had acute appendicitis duringpregnancy and who ha e undergone appendicectomy arewound infections, subphrenic abscesses, intestinal obstruc­tion. deep vein thrombosis, premature labour or abortion.fetal death and even maternal death.

CONCLUSIO

ausea and vomiting and poorly localised right upperabdominal pain in pregnancy are uggestive of acuteappendicitis. The prognosis of acute appendicitis in preg­nancy is directly proportional to the duration of symptomsand to whether perforation has occurred or not, and thekey to further improvement in the results of treatmentfor appendicitis in pregnancy i earlier diagnosis. A highindex of suspicion, and not the constellation of classicalclinical signs, is the indication for early operative treatment.

The dangers of a negative laparotomy are minimal,and early surgery is recommended. Conservative watch­fulness for more than 4 to 6 hours is condemned, for'the mortality of appendicitis in pregnancy and the puer­perium is the mortality of delay'."

REFERE ICES

1. Douelas. C. A. and McKinlay. P. L. (1935): Report on M,uernolMorbidity rind Mortality ill Scotland. p. 73. London: HMSO.

2. Child, C. G. and Douglas. R. G. (1944): Amer. l. Obstet. Gynec.,47. 213.

3. Taylor. l. D. (1972): Aust. '. Z. l. Obstet. Gynaec., 12. 202.4. Aird. I. (195): Companion in Surgical Studies. 2nd ed .. p. 51.

Edinburgh: E. & S. Livingstone.5. Barber, H. R. R. and Graber. E. A. (974): Surgical Disease in

Pregnancy, D. 86. Philadelphia: W. B. Saunders6. Louw. J. T. and Louw. l. H. (1954): S. Afr. Med. l., 28, 77. Warfield, G. r. (1950): Prostgrad. Med., 8, 10.

Rovinsky. l. l. and Guttmacher A. F. (1965): Medical. Surgical andGynecological Complications of Pregnancy. 2nd ed .. p. 241. Baltimore:Williams & Wilkins.

9. Alders, N. (1951): Brit. Med. l .. 2, 1194. _10. Rosemann. G. W. E. (1975): S. Afr. Med. l .. 49. 2)2.11. Finch. D. R. A. and Emanoel. Lee (1974): Brit. J. Surg .. 61, 129.12. Babler. E. A. (1908): l. Amer. Med. Assoc., 51. 1310.